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How I Know that my Patients Get Better?
These are questions I routinely ask other mental health clinicians I meet:
- How do you know your patients are getting better?
- What metrics do you track?
- How do you determine if other tools would benefit your patients?
- What other therapies could help your patient get better?
I’ve heard some outstanding answers from some. I have been impressed with the means some therapists and psychiatrists employ to ensure their patients/clients improve. Shockingly to me; however, this is not universal. Frankly, I’ve been amazed when the answer to these questions above are something like, “Well, my treatment must work, because they keep coming back.” Hmmm. This makes me wonder…
How We Do Better: Measure Progress
Thankfully, our medical record makes it extremely easy to track standardized symptom measures over time, so we can quantify our patients’ progress. We utilize the Generalized Anxiety Disorder 7-item Questionnaire (GAD-7) and the Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5). We routinely track clinically important metrics for all of our patients including baseline scores before SGB treatment. Focusing beyond diagnoses, I screen individual symptoms on these scales to assess if someone is a good candidate for SGB in the first place, even before scheduling them. Assessing individual symptoms on a PCL-5 and GAD-7 allows me to more intelligently counsel my patients on the likelihood of success from SGB treatment to address specific symptoms of theirs. Following SGB treatment, all of our patients reassess their symptoms at 1-week and again at 1-month post-SGB. We share with our patients their improvements by graphically portraying their symptom scores over time. We feel this is important to demonstrate that healing actually is possible! And, we can quantify gains our patients make when they resume therapy following their SGB treatment.
It is nice to look at a chart and see a down trending curve of your symptoms. But how do we know if this drop in symptoms is clinically meaningful? In medical terms we use what is called the MCID. This term “minimum clinically important difference” (MCID) describes the change in score of a particular measurement which is noticeable in a meaningful way to a patient. Score changes larger than the MCID likely reflect a real change in symptoms, rather than one due to variability. MCID values are used to tell us if a particular intervention causes a meaningful improvement in patient symptoms versus if the result is only a small change in numbers on a scale which does not really amount to much. Validated tools in medicine, including symptom questionnaires, have an MCID assigned. In our case, the MCID for the GAD-7 instrument is 4 points. Translated, this means that a drop in Anxiety symptoms of 4 points or more following an SGB treatment would be considered clinically important. For PTSD symptoms, we use the PCL-5 Checklist which has an MCID of 10 points. Again, if an intervention such as SGB results in a reduction of PCL-5 score by 10 points or greater, we would consider this to be a meaningful or clinically important improvement.
A Picture is Worth a Thousand Words
In the example here from one of our recent patients, we see that the Anxiety score (GAD-7) dropped by 16 points at 1-month after SGB treatment, which is four times the MCID. On the right side of the chart, we also see that baseline anxiety in the “Severe” range drops to below the “Mild” range to “Minimal” at one month. Below this, on the PTSD chart for the same patient, we see that the PCL-5 score before SGB treatment was 55 and fell to 11 points at 1-month after SGB, which is considered “subclinical” or below the threshold for a PTSD diagnosis. A reduction in PTSD score of 44 points is over four times the MCID for the PCL-5 checklist. These numbers are quite clinically meaningful and are fairly typical of the responses we see from most of our patients.
Stellate Ganglion Block is Not a Silver Bullet
We cannot attribute 100% of the gains patients make following SGB treatment to the SGB alone. Certainly, some symptom improvements occur quite dramatically soon after a stellate ganglion block; however, improvement over time depends on so many other factors. These factors include: regular follow ups with a therapist (IMO the #1 most important factor), healthy lifestyles including limited substance use, healthy relationships, and proper balance in stressful occupations. SGB does in fact seem to be the turning point for so many who have already tried their best to optimize all of these modifiable behaviors but are still held back by something. It turns out that the something holding them back may be their inappropriately elevated sympathetic nervous system (SNS) which seems to have hijacked their bodies and minds. This is very hard to break through with sheer willpower because the autonomic nervous system is so powerfully designed to keep us alive.
As crazy as it sounds (to some), sometimes the solution to an inappropriately elevated SNS is a simple 100-year-old injection. Why? Because stellate ganglion block helps reset the SNS activity by temporarily shutting off the signals in the cervical sympathetic trunk. This “resetting” in turn is what allows our patients to break through the biological barrier preventing them from achieving a calm body and a calm mind. As you can see, the graphs of follow-up symptom scores tell the story.
What Does Success Look Like?
Will everyone get better? No. Nothing in medicine is 100% successful; however, SGB success rates are around 85-90%. Will all of my patients have a dramatic drop in their symptoms after their first SGB? No, certainly not all, but a substantial number will in fact. Is SGB a silver bullet? Absolutely not, but it can be the key piece in breaking a dysfunctional SNS loop and allowing other therapies to be more effective.
So, success is not defined by every one of my patients reducing their PCL-5 and GAD-7 scores by 75%. Rather, for us, success looks like our best efforts to make this happen—providing quality care, time, and a staff who listens. For me, taking care of one person at a time is a worthwhile endeavor, and if I can relieve suffering every day for the patients sitting across from me, then that is a successful day.
Calm the body. Calm the mind.
